Ischemic Myelopathy Research Articles

Long-term results of treatment of a patient with basilar invagination complicated by distal kyphosis and compressive ischemic cervical myelopathy: a clinical case and a brief literature review

Objective. To present a clinical case of surgical correction of a craniovertebral anomaly complicated after 8 years by distal junctional kyphosis, stenosis, antelisthesis of the C5 vertebra and compressive ischemic cervical myelopathy in the C5–C6 segment.Material and Methods. When treating a 56-year-old patient with multiple anomalies of the craniovertebral region, differentiated surgical technologies were consistently used due to the development of late complications. The sequence and rationale for surgical decision making is described.Results. Initially, the patient underwent transoral decompression and posterior occipitocervical fixation, and after 8 years - reinstallation of the system with distal extension of the instrumentation zone to the C7 vertebra with indirect posterior decompression of the spinal cord, anterior discectomy with direct decompression and cage fixation at the C5–C6 level. Regression of myelopathic syndrome, correction of orthopedic status and significant improvement in functional status were achieved.Conclusion. A rare clinical observation demonstrates a combination of basilar invagination with assimilation of the atlas, which has provided rationale for two-stage surgical treatment in one surgical session (1st stage – transoral resection of the dens and 2/3 of the C2 vertebral body with anterior decompression of the spinal cord, and 2nd stage – occipitocervical fixation). The use of extended systems in this case caused the development of a clinically significant syndrome of the distal adjacent level, which required repeated surgical treatment after 8 years.

Outcome of the Use of Clinical Reasoning Alone in Dogs with Acute Thoracolumbar Myelopathy and/or Pain.

Acute thoracolumbar myelopathy is a common neurological presentation in dogs. Although certain spinal conditions present with characteristic clinical pictures, managing such cases with clinical reasoning alone (i.e., without cross-sectional imaging) has never been explored. The aim of this study was to define the outcome of patients with suspected intervertebral disc extrusion (IVDE), ischaemic myelopathy (IM) or acute non-compressive nucleus pulposus extrusion (ANNPE) that were managed with clinical reasoning alone. The database of the Queen's Veterinary School Hospital (Cambridge) was searched for paraparetic or paraplegic dogs with suspected IVDE or IM/ANNPE that were initially managed medically without undergoing imaging. Clinical presentation and outcome were recorded. If cross-sectional imaging was subsequently performed, information about the final diagnosis was collected and compared with the initially suspected diagnosis. A total of 123 IVDE cases were collected: 81% had a successful outcome with no imaging performed; 16% had IVDE confirmed with imaging and successful outcome with surgery or medical management; and just 3% were found to have an alternative diagnosis or were euthanised without imaging. A total of 16 IM/ANNPE cases were collected: 94% had a successful outcome, and one dog was euthanised. Successful outcomes can be obtained by using clinical reasoning alone in most dogs with suspected IVDE or IM/ANNPE.

Clinical signs, causes, and outcome of central cord syndrome in 22 cats.

To describe the signalment, clinical findings, presumptive or definitive diagnosis, and outcome in cats with central cord syndrome (CCS). 22 cats. Cats evaluated for CCS at 7 referral hospitals between 2017 and 2021 were included. Information retrieved from medical records included signalment, physical and neurological examination findings, diagnostic investigations, definitive or presumptive diagnosis, treatment, and follow-up. Median age at presentation was 9 years. Two neuroanatomical localizations were associated with CCS: C1-C5 spinal cord segments in 17 (77.3%) cats and C6-T2 spinal cord segments in 5 (22.7%) cats. Neuroanatomical localization did not correlate with lesion location on MRI in 8 (36.3%) cats. The most common lesion location within the vertebral column was over the C2 and C4 vertebral bodies in 6 (27.2%) and 5 (22.7%) cats, respectively. Peracute clinical signs were observed in 11 (50%) cats, acute in 1 (4.5%), subacute in 4 (18%), and chronic and progressive signs were seen in 6 (40.9%) cats. The most common peracute condition was ischemic myelopathy in 8 (36.3%) cats, whereas neoplasia was the most frequently identified chronic etiology occurring in 5 (22.7%) cats. Outcome was poor in 13 (59%) cats, consisting of 4 of 11 (36.6%) of the peracute cases, 3 of 4 (75%) of the subacute cases, and 6 of 6 of the chronic cases. Central cord syndrome can occur in cats with lesions in the C1-C5 and C6-T2 spinal cord segments. Multiple etiologies can cause CCS, most commonly, ischemic myelopathy and neoplasia. Prognosis depends on the etiology and onset of clinical signs.

Tube cystostomy is effective for urinary outflow management in dogs with intervertebral disk extrusion and ischemic myelopathy cranial to the L3 spinal cord segment: 61 dogs (2018-2022).

To describe the application and owner experience of tube cystostomy for management of upper motor neuron urinary bladder dysfunction secondary to intervertebral disk extrusion (IVDE) or ischemic myelopathy, and to report complications associated with cystostomy tube management. 61 dogs. Medical records of dogs with IVDE or ischemic myelopathy cranial to the L3 spinal cord segment that underwent tube cystostomy placement via a short, caudal ventral midline celiotomy were reviewed. Days from tube placement to hospital discharge, days from placement to tube removal, and complications were recorded. An owner questionnaire was distributed to ascertain ease of use and perceived time commitment. 58 dogs were diagnosed with IVDE, and 3 dogs were diagnosed with ischemic myelopathy. The modal neurologic grade at cystostomy tube placement was 4 (range, 3 to 5). The median number of days from cystostomy tube placement to hospital discharge was 1 (range, 0 to 3). Follow-up data was available for 56 dogs. The median number of days from cystostomy tube placement until removal was 19 (range, 3 to 74). Fifteen minor and 6 severe postoperative complications were reported, mainly inadvertent removal (n = 11) and peristomal urine leakage (6). Twenty-seven owners responded to the questionnaire and primarily reported that cystostomy tube use was easy (22/27) and perceived time commitment was low or minimal (20/27). Tube cystostomy facilitates early hospital discharge and allows at-home, extended urinary management in dogs recovering from upper motor neuron urinary bladder dysfunction secondary to IVDE or ischemic myelopathy. This technique is simple for owners to use.

Suspected ischaemic myelopathy following lumbosacral epidural steroid injection in a dog

AbstractAn 11‐year‐old, female, spayed crossbreed with an 18‐month history of degenerative lumbosacral stenosis presented for routine epidural steroid injection 4 months after previous injection. Following epidural steroid injection, the dog developed severe left hindlimb paresis with reduced to absent sciatic reflexes, delayed conscious proprioception in the limb, absence of anal tone and lower motor neuron urinary incontinence. Magnetic resonance imaging was performed, which demonstrated findings consistent with an ischaemic myelopathy. The dog's left hindlimb paresis improved on cage rest; however, urinary incontinence remained. The dog was subsequently euthanased due to quality‐of‐life concerns. This is the first published report of suspected ischaemic myelopathy developing in a dog after epidural steroid injection.

Epaxial muscle atrophy is more evident in large dogs with intervertebral disc disease than in dogs with ischaemic myelopathy

Cross-sectional area (CSA) decreases and fat infiltration increases in epaxial muscles of Dachshunds with intervertebral disc disease (IVDD), but less is known about large breed dogs with IVDD. The aim here was to investigate thoracolumbar epaxial muscle CSA and fat infiltration in large breed dogs with compressive IVDD and acute non-compressive nucleus pulposus extrusion (ANNPE) or fibrocartilaginous embolism (FCE).This retrospective study included large breed dogs with MRI-confirmed IVDD (n = 17) and ANNPE or FCE (n = 13). The CSA and fat infiltration of the thoracolumbar M. longissimus and Mm. multifidi were assessed from T1-weighted transverse MR images using Osirix.The CSA was significantly smaller in dogs with compressive IVDD than in dogs with non-compressive ANNPE or FCE for Mm. multifidi (p = 0.015), M. longissimus (p = 0.070), and these two muscles combined (p = 0.016). Fat infiltration in all muscle measurements was significantly higher in dogs with compressive IVDD than in dogs with non-compressive ANNPE or FCE (all P < 0.050). A significant positive correlation existed between age, duration of clinical signs, and fat infiltration, suggesting more fat infiltration in older dogs with more chronic signs.These signs of muscle atrophy are likely caused by denervation and secondary disuse due to chronic spinal cord compression and prolonged duration of clinical signs.

Magnetic Resonance Imaging in 50 Captive Non-domestic Felids - Technique and Imaging Diagnoses.

Magnetic resonance imaging (MRI) is the recognized gold standard for diagnostic imaging of the central nervous system in human and veterinary patients. Information on the use of this modality and possible imaging abnormalities in captive non-domestic felids is currently limited to individual case reports or small case series. This retrospective study provides information on technique and imaging findings in a cohort of cases undergoing MRI at an academic Veterinary Medical Center. The University of Tennessee College of Veterinary Medicine MRI database was searched for non-domestic felids undergoing MRI of the brain or spine from 2008 to 2021. Medical record data were recorded, and MRI studies were reviewed. Fifty animals met the inclusion criteria. The most common brain diseases were Chiari-like malformation (n = 8) and inflammatory conditions (n = 8). Other abnormalities included pituitary lesions (n = 5), brain atrophy (n = 2), and one each of metabolic and traumatic conditions. Fourteen animals had a normal brain MRI study. The most common spinal abnormality was intervertebral disc disease (n = 7). Other disorders included vertebral dysplasia (n = 2), presumptive ischemic myelopathy (n = 1), subdural ossification causing spinal cord compression (n = 1), and multiple myeloma (n = 1). Spinal cord swelling of undetermined cause was suspected in two animals, and seven patients had a normal MRI study of the spine. MRI is a valuable tool in the diagnostic workup of non-domestic felids with presumptive neurologic disease.

Cocaine-related cervical spinal cord infarction: a\xa0case report and review of the\xa0literature

Study designCase report.ObjectivesTo report a clinical case of spinal cord infarction due to cocaine use.SettingSpinal Center, IRCCS Fondazione S. Lucia, Rome (Italy).Case presentationTwo days after recreational use of cocaine, a 27-year-old Caucasic man was admitted to the emergency department for acute cervical pain, weakness in all four limbs, and urinary retention. A cervical spinal magnetic resonance imaging scan, performed after 2 days, showed a “pencil-like” lesion extending from C4 to T1 metamer, compatible with acute ischemia in the anterior spinal artery territory. Other causes of vascular disorders, as well as inflammatory and infectious disorders were ruled out. At admission in our department, the patient had an incomplete tetraplegia at level C6, an indwelling catheter, and was unable to stand and walk. After 3 months of rehabilitation, he had an AIS score D tetraplegia at level C7, was able to stand and walk using parallel bars, and indwelling catheter was replaced by intermittent catheterization.Discussion and conclusionsThe etiology of medullary infarction may remain unexplained in nearly 30–40% of cases. Even if rare, cocaine-induced ischemic myelopathy should be considered and ruled out in the differential diagnosis of any acute nontraumatic myelopathy, especially in young patients.

Teaching NeuroImage: Pontine Owl-Eyes Lesions in a Case of Neuroborreliosis.

Brain MRI in a 65-year-old woman with headache, sensory ataxia, and tick exposure revealed leptomeningeal and cranial nerve enhancement and T2-hyperintense symmetrical pontine lesions resembling the “owl-eyes” sign, a radiologic finding described in ischemic or compressive myelopathy (Figure, A–C).1 CSF analysis revealed pleocytosis (163/µL) and intrathecal production of anti- Borrelia IgG (CSF/serum index 21, N < 2). Workup was negative for alternative causes. The patient fully recovered after 21 days of ceftriaxone (Figure, D–F).

Ischaemic myelopathy in a cat with chronic kidney disease, hyperthyroidism, and hyperaldosteronism

AbstractIschaemic myelopathy (IM) in cats often affects the cervical region. It is generally associated with an underlying predisposing condition with systemic arterial hypertension due to chronic kidney disease and cardiomyopathies the most frequently reported. The present case report describes the successful management of an old cat presented for acute onset of weakness, neck ventroflexion, and ataxia as a result of cervical IM secondary to severe systemic hypertension associated with hyperthyroidism, chronic renal disease, and primary hyperaldosteronism. Feline cervical IM carries a favourable prognosis with resolution of neurological deficits unless the underlying medical condition is not resolved, favouring further ischaemic events.

Reduced field-of-view diffusion-weighted MRI can identify restricted diffusion in the spinal cord of dogs and cats with presumptive clinical and high-field MRI diagnosis of acute ischemic myelopathy.

Diffusion-weighted imaging MRI is the gold standard imaging technique for diagnosis of suspected acute brain ischemia in dogs and cats; however, it is technically challenging to apply to spinal cord imaging, due to its very small size, the inherent low spatial resolution of diffusion-weighted imaging, and the marked distortion resulting from magnetic field inhomogeneities caused by the osseous components of the vertebral column surrounding the spinal cord. Ischemic myelopathy is a common cause of acute non-compressive myelopathy in dogs and cats. Technological improvement in diffusion-weighted imaging pulse sequences allow imaging at smaller field of view with better spatial resolution and less image distortion. We sought to evaluate reduced field-of-view diffusion-weighted imaging MRI using a dedicated proprietary pulse sequence (FOCUS, General Electric) in a small sample of dogs and cats with a presumptive clinical and MRI diagnosis of acute ischemic myelopathy that were imaged with this pulse sequence. Five dogs and two cats fitted these inclusion criteria. In all of them, hyperintense spinal cord parenchyma signal was seen on diffusion-weighted imaging images corresponding to decreased signal on apparent diffusion coefficient map indicative of restricted diffusion, consistent with ischemia and cytotoxic edema. These areas matched the areas of abnormal T2-weighted signal and cord swelling observed on conventional spinal MRI. This small exploratory descriptive study indicates feasibility and possible usefulness of reduced field-of-view diffusion-weighted imaging MRI in dogs and cats with suspected acute ischemic myelopathy and that it may be added to the imaging protocol of the spine in such patients in an appropriate clinical setting.

Ischemic myelopathy as a perioperative complication of Percutaneous Coronary Intervention via Femoral Approach (4694)

Ischemic myelopathy as a perioperative complication of Percutaneous Coronary Intervention via Femoral Approach (4694)

Retroperitoneal approach for the treatment of diaphragmatic crus syndrome: technical note.

Myelopathy selectively involving the lower extremities can occur secondary to spondylotic changes, tumor, vascular malformations, or thoracolumbar cord ischemia. Vascular causes of myelopathy are rarely described. An uncommon etiology within this category is diaphragmatic crus syndrome, in which compression of an intersegmental artery supplying the cord leads to myelopathy. The authors present the operative technique for treating this syndrome, describing their experience with 3 patients treated for acute-onset lower-extremity myelopathy secondary to hypoperfusion of the anterior spinal artery. All patients had compression of a lumbar intersegmental artery supplying the cord; the compression was caused by the diaphragmatic crus. Compression of the intersegmental artery was probably producing the patients' symptoms by decreasing blood flow through the artery of Adamkiewicz, causing lumbosacral ischemia. All patients underwent surgery to transect the offending diaphragmatic crus. Each patient experienced substantial symptom improvement, and 2 patients made a full neurological recovery before discharge. Diaphragmatic crus syndrome is a rare or under-recognized cause of ischemic myelopathy. Patients present with episodic acute-on-chronic lower-extremity paraparesis, gait instability, and numbness. Angiography confirms compression of an intersegmental artery that gives rise to a dominant radiculomedullary artery. Transecting the offending diaphragmatic crus can produce complete resolution of neurological symptoms.

Vascular Ischemic Myelopathy in Adolescents and Young Adults: What Should One Know?

We present 3 cases of adolescents and young adult with vascular ischemic myelopathy, 2 of which were associated with sports (surfing and water polo), and a third of a patient with a fibrocartilaginous embolism related to a trivial fall from a forklift. These are rare clinical presentations in adolescents and with poor prognosis in most cases. This article describes their clinical presentations in detail and offers a review of the literature with emphasis on the imaging findings and differential diagnosis.

Spinal nephroblastoma in a dog: a case report

The case report presents the clinical, clinicopathological, diagnostic imaging and histopathological findings of spinal cord nephroblastoma in a dog. It was admitted with a 2-week history of a “weight-bearing” lameness of the left posterior limb that evolved to paraplegia within hours. Neurological examination showed spastic paraplegia compatible with a T3-L3 spinal cord lesion. Differential diagnosis included ischemic myelopathy, myelitis and acute spinal cord compression. The spinal radiographs and cerebrospinal fluid analysis were unremarkable. Cisternal myelography indicated a focal intradural-extramedullary lesion at the level of T12 vertebra. Further diagnostic investigation was not performed because the owner decided to proceed to euthanasia. Histopathological examination of the spinal cord confirmed the diagnosis of intraspinal nephroblastoma.

A Case Report of Reverse Split-hand Syndrome: An Overlooked Clinical Sign of Hirayama Disease

Hirayama disease (HD) is considered to be a relatively benign, slowly progressive and less disabling rare neurological disorder where flexion induced compressive ischemic lower cervical myelopathy causes selective anterior horn cell injury resulting weakness and atrophy of distal upper limb without any pyramidal, spinothalamic and posterior column disturbance. Herein, we report a young male with clinical and imaging features suggestive of Hirayama disease presented with dissociated hand muscle atrophy (hypothenar more affected than thenar) in both hands. This less recognized finding was previously termed as reverse split-hand syndrome just opposite to split-hand syndrome found in amyotrophic lateral sclerosis. We also observe electrophysiological correlation of reverse split-hand syndrome in HD.&#x0D; Bangladesh Journal of Neuroscience 2019; Vol. 35 (2): 110-114

Clinical reasoning in feline spinal disease: which combination of clinical information is useful?

The aim of this study was to evaluate if a combination of discrete clinical characteristics can be used to identify the most likely differential diagnoses in cats with spinal disease. Two hundred and twenty-one cats referred for further evaluation of spinal disease were included and categorised as follows: non-lymphoid neoplasia (n = 44); intervertebral disc disease (n = 42); fracture/luxation (n = 34); ischaemic myelopathy (n = 22); feline infectious peritonitis virus myelitis (n = 18); lymphoma (n = 16); thoracic vertebral canal stenosis (n = 11); acute non-compressive nucleus pulposus extrusion (n = 11); traumatic spinal cord contusion (n = 8); spinal arachnoid diverticula (n = 7); lumbosacral stenosis (n = 5); and spinal empyema (n = 3). Information retrieved from the medical records included signalment, clinical history and clinical presentation. Univariate analyses of variables (clinical history, breed, age, sex, general physical examination findings, onset, progression, spinal hyperaesthesia, asymmetry, ambulatory status and neuroanatomical location) were performed, and variables were retained in a multivariate logistic regression model if P <0.05. Multivariate logistic regression revealed that intervertebral disc disease most often occurred in middle-aged, purebred cats with a normal general physical examination and an acute onset of painful and progressive clinical signs. Ischaemic myelopathy occurred most often in older cats with a stable or improving, non-painful, lateralising, C6-T2 myelopathy. Spinal fracture/luxation occurred most often in younger cats and resulted most often in a peracute onset, painful, non-ambulatory neurological status. Concurrent systemic abnormalities or abnormal findings detected on general physical examination were significantly associated with feline infectious peritonitis virus myelitis, spinal lymphoma or spinal empyema. This study suggests that using easily identifiable characteristics from the history and clinical examination can assist in obtaining a preliminary differential diagnosis when evaluating cats with spinal disease. This information could aid veterinary practitioners in clinical decision-making.

Ischemic myelopathy caused by fibrocartilaginous embolism in a horse

ABSTRACT: This report described clinical, epidemiological, and pathological aspects of ischemic myelopathy caused by fibrocartilaginous embolism (FCE) in a 10-year-old, mixed breed gelding. Clinically, the horse presented acute hind limbs paralysis, with a clinical course of approximately 24 hours. At necropsy, no gross lesions were observed. Cross-sections of the spinal cord revealed focally extensive areas of malacia from the T10 to L4 segments. Focally extensive areas of liquefactive necrosis involving the gray matter and adjacent white matter were observed on histologic sections. The lumen of multiple blood vessels in the periphery of the necrotic areas was occluded by fibrocartilaginous emboli that strongly stained with alcian blue. Clinical signs, gross necropsy, and histological findings observed in this case were identical to those described in the literature for ischemic myelopathy caused by FCE in the horse and other species.

Spinal Myoclonus Responding to Continuous Intrathecal Morphine Pump.

Spinal myoclonus is a sudden, brief, and involuntary movement of segmental or propriospinal muscle groups. Spinal myoclonus has occasionally been reported in patients undergoing opioid therapy, but the pathophysiology of opioid-induced myoclonus has not been elucidated yet. Here, we present two patients with spinal segmental myoclonus secondary to ischemic and radiation myelopathy. Conventional medications did not help treat persistent myoclonus in both legs. Continuous intrathecal morphine infusion was implanted for pain control in one patient, which relieved spinal myoclonus entirely. This experience led to the application of this method with a second patient, leading to the same gratifying result. Spinal myoclonus reemerged as soon as the morphine pumps were off, which confirmed the therapeutic role of opioids. In contrast to the opioid-induced myoclonus, these cases show a benefit of opioids on spinal myoclonus, which could be explained by synaptic reorganization after pathologic insults in the spinal cord.

Neurological manifestations in dogs naturally infected by Leishmania infantum: descriptions of 10 cases and a review of the literature.

In order to evaluate possible nervous system involvement in canine leishmaniasis, retrospective evaluation of all medical records of leishmaniotic dogs exhibiting neurological signs referred to our hospital over a 5-year period was performed. The records of 10 dogs were reviewed. Depending on the neuroanatomical localisation, the dogs underwent advanced diagnostic imaging, cerebrospinal fluid analysis, electrodiagnostic testing and histopathologic evaluations. The final neurological diagnosis was: meningoencephalitis (n=2), brain haemorrhagic stroke (n=1), haemorrhagic choroiditis (n=1), meningomyelitis (n=2), ischaemic myelopathy (n=1), polymyositis (n=2) and peripheral neuropathy (n=1). This study confirms that both central and peripheral nervous systems can be affected by leishmaniasis and provides an overview on the possible etiopathogenetic mechanisms. In addition, clinical and diagnostic findings, therapy and follow-up of affected dogs are described.